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Medical Problems Meds
=Common Medical Problems and Medications to have on board= :Roy Verdery, MD, Internal Medicine (medicine for adults) :February - March, 2009 Disclaimer - read this first! Do not use these general rules for children or pregnant women without input from a pediatrician or an obstetrician. '' This information is provided for educational purposes only, to help people decide which medications to have on board, and to assist people who may be some distance from a physician in making informed decisions. It is not designed to substitute for professional care or to teach medicine to non-physicians. There may be errors and omissions in spite of efforts to be accurate and complete. Get help if the problem doesn’t get better in 3 days, gets worse, or isn’t nearly gone in 7 days. In all cases it is better to see a physician or other health care provider or to communicate with a physician by any means available than to treat yourself or to act as a doctor without proper training and credentials. Local physicians have lots of experience, even if they weren’t trained in the US, Canada, or EU. 90% of medical problems are self-limited and require no treatment at all and a doctor who takes care of himself has a fool for a physician.'' ' When taking care of other people, remember that the first rule is to do no harm.' =Getting medical assistance= For serious problems In 2009, the standard is to get help and evacuate to a major medical center. Before buying a complex medical kit, buy a satellite phone and keep handy a telephone number of a physician you can count on and the U.S. Coast Guard. Additionally, there are thousands of Hams waiting 24 hr per day on single sideband radio (SSB) at 14300 kHz upper sideband to help in emergencies; and of course, the local VHF and SSB radio nets have people with vast amounts of experience and resources who will help you. Cruising is a social activity and there are many people who are willing to help. Pharmacists Outside of the U.S., Canada, U.K., and the E.U. pharmacists are not usually credentialed. Often they are just salespeople who sell medications. Be very careful accepting the advice of pharmacists, even for simple problems such as colds and diarrhea. Medication names Generic medication names are primarily used in the following notes. These are the names most recognizable by pharmacists and physicians in various countries. Unfortunately there are three different lists of generic names: the U.S., the U.K., and WHO (which seems to have chosen from the U.S. and U.K. lists). In Mexico, the WHO list is used. For example, Tylenol is the brand name for U.S. acetaminophen and U.K. paracetamol. Mexico uses the WHO generic name paracetamol for this drug. Read the ingredients of combination drugs, such as cold medications carefully. Many combination drugs contain sedatives and stimulants or use doses which are not approved for sale over the counter in the U.S., Canada, U.K., or E.U. =Common problems expected= Based on experience with around the world sailors, an otherwise healthy cruiser can expect to have 4 medical illnesses a year: 1 stomach ailment (heartburn, gastroenteritis, or diarrhea), 1 cold, 1 rash, and 1 episode of seasickness or other common problem. The same cruiser can expect to have 3 injuries per year: 1 scrape or bruise, 1 sprain or minor fracture, and 1wound or burn. Head injuries occur about once every 5 years of cruising. You should prepare yourself for the common problems that can be expected and for the simple problems that anyone might encounter in day to day living. Common expected problems and over-the-counter (otc) medications needed: Medications for Common Problems Heartburn Calcium carbonate (Tums), magnesium and aluminum hydroxide antacid (Maalox or Mylanta), ranitidine (Zantac), omprazole (Prilosec), or famotidine (Pepcid). Diarrhea Oral hydration electrolytes or know how to make oral hydration fluid, Immodium AD, Peptobismol. Gastroenteritis Oral hydration electrolytes or know how to make oral hydration fluid. Cold or flu Acetaminophen (Tylenol), dm cough syrup, throat lozenges, sudafed, benadryl, favorite otc cold medication. Rash 1% hydrocortisone cream, antifungal cream (terbinifine, lotrimin, tolnaftate, miconazole, clotrimazole, or ketoconazole). Allergy Loratidine (Clariten) or diphenhydramine (Benadryl) along with acetaminophen (Tylenol), ibuprofen, or naproxen for itch. People with history of severe allergic reactions associated with shortness of breath, fainting, shock, swelling of the throat, or low blood pressure should carry injectable epinephrine (EpiPen) and know how to use it. They should also show their companions what to do in the event of a severe reaction. Seasickness Meclizine (Bonine or Non-drowsy Dramamine), diphenhydramine (Dramamine), compazine, phenergan, cinnarizine (Stugeron), and/or transdermal scopolamine. Scrape or bruise Soap and water, antibiotic cream, bandaids and other sterile bandages. Sprain or minor fracture Ace bandage and/or splint, ice, tylenol, ibuprofen, naproxen, or other nonsteroidal antiinflammatory. Immobilization, ice, elevation, and pain control are the principal aspects of treatment. A minor fracture is one which cannot be distinguished from a sprain without an x-ray. Get help if there is severe deformity, wound, visible bone, or if pain doesn't improve in 3-7 days. Wound Soap and water, antibiotic cream, sterile bandages. Wash wounds twice daily with gentle soap, rinse well with fresh water, pat dry, cover with a sterile dressing and keep dry. Note that no wounds MUST be closed and many wounds, especially if contaminated with sea water, dirt, sand or other embedded material, should NEVER be closed. Use direct pressure to stop bleeding, being especially careful with neck wounds. Call for help if bleeding doesn't stop. Use butterfly bandages if needed to help bring edges of wounds together but remove them if infection (redness, pain, swelling, pus, or warmth) develops. Suturing or stapling wounds causes small puncture wounds and should be done after a prophylactic tetanus shot. Do not suture or staple wounds unless you have professional training and can establish a "sterile field." Burn Antibiotic cream, sterile bandages, tylenol, ibuprofen, or naproxen Less Common Problems and Medications to Consider :: =Non-prescription medications= Non-prescription medications mentioned are listed below with approximate dosing. It is best for them to be taken as directed on the package or bottle. Be careful to avoid medication allergies. *'acetaminophen' (Tylenol), 325 or 500 mg, 1-2, 4 times daily, risk of overdose with more than 4000 mg / day *'ibuprofen' 200 mg otc, 1-2, 4 times daily, risk of stomach pain, bleeding from the stomach, and ulcers (take omeprazole or pepcid to prevent stomach problems) *'naproxen' 250 (220 otc, Aleve) mg, 1-2, 2 times daily, risk of stomach pain, bleeding from the stomach, and ulcers (take omeprazole or pepcid to prevent stomach problems) *'nonsteroidal antiinflammatories' include many drugs (e.g. salsalate, trisilate, ibuprofen, ketoprofen, naproxen, diclofenac, etodolac, indomethecin, ketorelac, nabumetone, sulindac, tolmetin, meclofenamate, meloxicam, prioxicam, celecoxib) with similar benefits. All require different doses and dosing intervals, all have risk of stomach pain, bleeding from the stomach, and ulcers (take omeprazole or pepcid to prevent stomach problems) *'aspirin', 325 mg, 1-2, 4 times daily (1, once for cardiac chest pain) *'artificial tears' eye drops, 1-2 drops in both eyes as needed *'Nafcon' a eye drops, 1-2 drops in both eyes, 1-2 times daily *'Debrox' ear drops, 2 drops in the affected ear, 2 times daily, not if eardrum is perforated *'pseudoephedrine' (Sudafed), 30 mg, 1-2 up to 4 times daily, raises blood pressure, causes insomnia *'Afrin' nasal spray, both nostrils up to 4 times daily, habit forming (if you stop you get worse) *'diphenhydramine' (Benadryl), 12.5 - 50 mg up to 4 times daily, causes sleepiness *'loratadine', 25 mg daily *'clotrimazole' suppositories, dissolve in the mouth 4 times daily for thrush (yeast infection) *'dm cough syrup' (e.g. Robitussin dm, Honey dm), 1 teaspoon every 3 hours *'throat lozenges', dissolve in mouth as needed *'calcium carbonate' (Tums), 2 every 2 hours as needed *'magnesium and aluminum hydroxide' (Maalox or Mylanta), 2 tablespoons every 2 hours as needed *'zantac' (Ranitidine), 150 mg, 1-2, 1 time or 2 times daily *'omeprazole' (Prilosec) or famotidine (Pepcid), 20mg, 1 in the morning *'oral rehydration' fluid made from packaged electrolytes or mix 1/2 teaspoon salt, 1/2 teaspoon baking powder, 1/4 teaspoon potassium chloride, and 2 tablespoons sugar or corn syrup in 1 quart of water. Even simpler, use 1/2 teaspoon salt and 1 tablespoon sugar in 1 quart water. *'dimenhydrinate' (Dramamine) 12.5 - 25 mg to 4 times daily, causes sleepiness, ok for children *'meclizine' (Bonine) 12.5 - 25 mg twice daily *'scopolamine' patch (Transderm Scop), ½ -1 patch to skin every 3 days, wash hands after applying. If you get scopolamine in your eye it will dilate the pupil on that side - patch the eye, wear dark glasses, and wait for the pupil to return to normal. *'phenergan' 12.5 - 25 mg twice daily *'compazine' 12.5 -25 mg twice daily *'cinnarizine' (Stugeron), 15 mg twice daily for seasickness per U.K pharmacopoeia, not for children (Warning: 75 mg tablets are used for heart disease, not seasickness.) *'topical “azole” ' (miconazole, clotrimazole, butoconazole, terconazole, or tioconazole, e.g. Monistat 3 or 7) for vaginal yeast infections *'immodium' 2.5 mg, 2 with loose bm and 1 with next loose bm to 6 per day maximum *'bisthmus subsalicylate' (Peptobismol), 2 tablespoons or 2 wafers every 2 hours as needed, turns stools black *'Metamucil', 1 teaspoon with 8 oz glass of water or juice twice daily, for constipation or persistent loose stools after episode of diarrhea. (Not a laxative, just provides bulk.) *'docusate sodium', 200 mg, 1-4 times daily, for constipation *'magnesium hydroxide' (Milk of Magnesia), 2 tablespoons, 1-4 times daily if no bm in 2 days *'enema', if constipated more than 3 days *'hydrocortisone' 0.5 - 1% cream *'antifungal cream' (terbinifine, lotrimin, tolnaftate, miconazole, clotrimazole, or ketoconazole creams are similar, but one may work when another doesn’t) =Prescription medications= Prescription medications mentioned are listed below, with approximate dosing based on The Sanford Guide to Antimicrobial Therapy 2008. Be very careful to avoid allergies. There are many alternatives, discuss them with your physician. *gentamycin eye drops 1 drop, every 2 hours while awake for 3 days, may cause redness *tobramycin eye drops 1 drop, every 2 hours while awake for 3 days, may cause redness *cortisporin ear drops 1-2 drops, 2 times daily for 3 days *trimethoprim / sulfamethoxazole (tm-smx, Bactrim) 160 / 800 mg, 2 times daily for 7 days, sulfa - consider allergies *amoxicillin 500 mg, 3 times daily for 7 days, penicillin - consider allergies *penicillin vk 500 mg, 4 times daily for 7 days, penicillin - consider allergies *ciprofloxacin (Cipro) 500 mg, 2 times daily for 7 days (3 days for diarrhea), not for children *doxycycline 100 mg, 2 time daily for 7 days *nitrofurantoin 50 mg, 4 times daily for 7 days (macrobid 2 times daily is same) *macrobid 100 mg, 2 times daily for 7 days *albuterol inhaler 2 puffs, 4 times daily and every 2 hours as needed *prednisone 5 mg, 4 tablets one time a day for 3 days, then 2 tablets one time a day for 3 days, then 1 tablet daily for 3 days (many versions of this regimen are commonly recommended, discuss with your physician) *clindamycin 300 mg, 4 times daily for 7 days *cephalexin (Keflex) 500 mg, 4 times daily for 7 days *nitroglycerin 0.4 mg, 1 under the tongue every 5 minutes while lying down *atenolol 25 mg, 1daily for cardiac chest pain, not with metoprolol *metoprolol 25 mg, 1 2 times daily for cardiac chest pain, not with atenolol *metronidazole (Flagyl) 500 mg, 4 times daily for 7 days Carry inexpensive medications and keep them up-to-date. There are no controlled trials addressing shelf life. It is certainly shorter in hot and humid weather. =Antibiotic recommendations 2009= Antibiotic principles Antibiotics are often not needed. Many infections can be treated without antibiotics. Many infections, especially upper respiratory infections such as sinusitis, sore throat, earaches, and the “flu” are caused by viruses and don’t require antibiotics. Even bronchitis and pneumonia are often caused by viruses. On the other hand, most women have had a urinary tract infection, recognize the symptoms, and need an antibiotic. Additionally, there are a few healthy people every year who develop bacterial infections and whose symptoms progress from mild to severe to death in 2 or 3 days even in the U.S. For example, streptococcal pneumonia still kills healthy young people. In 2009, the standard is to get advice before you treat yourself or someone else. Use your satellite phone, SSB, or VHF radio to get professional advice. Choosing an antibiotic Antibiotics kill or inhibit growth of bacteria, allowing the body to cure an infection. Ideally, you find out what bacteria is causing the infection, test antibiotics to determine which are effective against that particular bacteria, and then take the exactly correct antibiotic. If you don’t know what bacteria is causing an infection and still need an antibiotic, you need “empiric” treatment. That is, based on the kind of infection, you guess which bacteria is causing the problem, and you guess what is the best antibiotic. Some of these choices are easy. Traveler’s diarrhea is most often caused by E. coli or Salmonella or a related bacteria. Ciprofloxacin kills most of these bacteria. Moreover, people get over traveler’s diarrhea without any treatment. Killing the bacteria just shortens the number of days with diarrhea. The CDC recommends 3 days of ciprofloxacin for traveler’s diarrhea, a safe empiric recommendation. Other choices are harder. Urinary tract infections (bladder infections, kidney infections, prostate infections) are caused by a number of different bacteria. Often ciprofloxacin works. However, many bacteria are now resistant to ciprofloxacin so alternative antibiotics my work better. Even more complex are infections of the skin and lungs (pneumonia or bronchitis). Many different bacteria can cause skin and lung infections and the choice of antibiotic is difficult, though there are standard treatments which are recommended every year based on previous experience. For pneumonia, it is important to have several possible antibiotics to choose from. And, ciprofloxacin is not generally effective against bacteria in the respiratory system. Recommendation The basic idea is to have 4 or 5 broad spectrum antibiotics along with a few antibiotics for specific infections available. A single, 10-day course is probably enough to carry unless you expect many infections or have many people to care for. What you carry should be inexpensive so you replace them when they are out-dated. There are no controlled trials addressing shelf life. Shelf life is certainly shorter in hot and humid weather. Conclusion A small supply of ciprofloxacin, trimethoprim - sulfamethoxazole, amoxicillin, doxycycline, metronidazole, and fluconazole (for women) along with ear end eye drops should cost about $100 from a discount pharmacy such as Costco. These antibiotics would provide a first line drug for most infections. They are inexpensive enough that they can be discarded when they are outdated. There are many alternative antibiotics and no single correct list. Many people are allergic to one or another antibiotic, so pay close attention to allergies. It is best to not carry drugs which anyone on board is allergic to. The following tables give information about usefulness of other antibiotics along with contraindications. They can be used to choose alternative antibiotics based on allergies and availability. Antibiotics for use with particular infections Table I Antibiotics for use with particular infections See Table II for contraindications and common adverse reactions. See Table III for doses and estimate cost from a discount pharmacy. Notes regarding Table I: "Brand" is a representative brand name in the U.S. Numbers 1 - 3 indicate first, second, or third most useful drug for this kind of infection. These numerals do not necessarily indicate the “best” drug, rather they indicate which drug is most likely to be effective. These numbers are based on Dr. Verdery’s training and experience and are similar to recommendations form The Sanford Guide to Antimicrobial Therapy 2008. They are educational guidelines for empiric therapy to help choose antibiotics to carry on board, and are not medical recommendations for treating a specific infection in a specific person. Discuss antibiotic treatment with a medical professional before treating yourself or another person. If one antibiotic does not work, another, different one may work better for a specific infection. "Skin" has been simplified since skin infections include acne, boils, cellulitis, bites by various animals, and wound infections. Some antibiotics are more effective than others in particular skin infections. "Urinary tract" includes bladder, kidney, and prostate. Asterisk * indicates that the antibiotic must be taken with a second antibiotic to be useful for this condition. Discussion with a healthcare provider is especially important when 2 or more drugs are needed. Other antibiotics: 1. Women should have fluconazole 150 mg one time (1 dose is $7) or an “azole” (miconazole, clotrimazole, butoconazole, terconazole, or tioconazole) topical preparation for vaginal yeast infections. 2. An ear antibiotic, such as cortisporin otic ear drops, and an eye antibiotic, such as gentamycin or tobramycin optic eye drops are also important to have available. Table II Contraindications and adverse reactions Table III Recommended doses, supply and estimate cost of generic supply =Recommended references:= Many popular books on medicine for cruisers on boats are out of date. Beware of any book published more than 5 years ago. Weiss, Eric A. and Jacobs, Michael: A Comprehensive Guide to Marine Medicine. Adventure Medical Kits, Oakland, CA. 2005. Note: the formula for oral hydration solution has typographical errors. Arguin, Paul, M., Kozarsky, Phyllis E., and Reed, Christie, eds. CDC Health Information for International Travel. Elsevier Mosby, Philadelphia, PA. 2008. Note: the formula for oral hydration solution has typographical errors. *© Roy Verdery 2009. All rights reserved. Permission to copy these notes is granted for noncommercial purposes only.